van der Kooij S M, Goekoop-Ruiterman Y P M, de Vries-Bouwstra J K, Güler-Yüksel M, Zwinderman A H, Kerstens P J S M, van der Lubbe P A H M, de Beus W M, Grillet B A M, Ronday H K, Huizinga T W J, Breedveld F C, Dijkmans B A C, Allaart C F
Leiden University Medical Center, The Netherlands.
Ann Rheum Dis. 2009 Jun;68(6):914-21. doi: 10.1136/ard.2008.092254. Epub 2008 Jul 28.
To compare the occurrence of drug-free remission, functional ability and radiological damage after 4 years of response-driven treatment according to four different treatment strategies for rheumatoid arthritis (RA).
Patients with recent-onset, active RA (n = 508) were randomly assigned to four different treatment strategies: (1) sequential monotherapy; (2) step-up combination therapy; (3) initial combination therapy with prednisone and (4) initial combination therapy with infliximab. Treatment was adjusted based on 3-monthly disease activity score (DAS) assessments, aiming at a DAS < or =2.4. From the third year, patients with a sustained DAS <1.6 discontinued treatment.
In total, 43% of patients were in remission (DAS <1.6) at 4 years and 13% were in drug-free remission: 14%, 12%, 8% and 18% of patients in groups 1-4, respectively. The absence of anti-cyclic citrullinated peptide antibodies, male gender and short symptom duration were independently associated with drug-free remission. Functional ability and remission were maintained in all four groups with the continuation of DAS-driven treatment, without significant differences between the groups. Significant progression of joint damage was observed in 38% and 31% of patients in groups 3 and 4 versus 51% and 54% of patients in groups 1 and 2 (p<0.05, group 4 versus groups 1 and 2, group 3 versus group 2).
In patients with recent-onset active RA, drug-free remission was achieved in up to 18% of patients. DAS-driven treatment maintained clinical and functional improvement, independent of the treatment strategy. Joint damage progression remained significantly lower after initial combination therapy compared with initial monotherapy.
根据类风湿关节炎（RA）的四种不同治疗策略，比较反应驱动治疗4年后无药物缓解的发生率、功能能力和放射学损伤情况。
将近期发病的活动性RA患者（n = 508）随机分配至四种不同治疗策略组：（1）序贯单药治疗；（2）逐步联合治疗；（3）联合泼尼松初始联合治疗；（4）联合英夫利昔单抗初始联合治疗。根据每3个月的疾病活动评分（DAS）评估调整治疗，目标是DAS≤2.4。从第三年起，持续DAS<1.6的患者停止治疗。
4年时，共有43%的患者处于缓解状态（DAS<1.6），13%的患者实现无药物缓解：第1 - 4组患者分别为14%、12%、8%和18%。抗环瓜氨酸肽抗体阴性、男性性别和症状持续时间短与无药物缓解独立相关。在所有四组中，随着DAS驱动治疗的持续，功能能力和缓解得以维持，组间无显著差异。第3组和第4组分别有38%和31%的患者出现关节损伤显著进展，而第1组和第2组分别为51%和54%（p<0.05，第4组与第1组和第2组相比，第3组与第2组相比）。
在近期发病的活动性RA患者中，高达18%的患者实现了无药物缓解。DAS驱动治疗维持了临床和功能改善，与治疗策略无关。与初始单药治疗相比，初始联合治疗后关节损伤进展仍显著更低。
